Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients With COVID-19

Abstract

Importance: Full-thickness tracheal lesions and tracheoesophageal fistulas are severe complications of invasive mechanical ventilation. The incidence of tracheal complications in ventilated patients with coronavirus disease 2019 (COVID-19) is unknown.

Objective: To evaluate whether patients with COVID-19 have a higher incidence of full-thickness tracheal lesions and tracheoesophageal fistulas than matched controls and to investigate potential mechanisms.

Design, setting, and participants: This is a retrospective cohort study in patients admitted to the intensive care unit in a tertiary referral hospital. Among 98 consecutive patients with COVID-19 with severe respiratory failure, 30 underwent prolonged (≥14 days) invasive mechanical ventilation and were included in the COVID-19 group. The control group included 45 patients without COVID-19. Patients with COVID-19 were selected from March 1 to May 31, 2020, while the control group was selected from March 1 to May 31, 2019.

Exposures: Patients with COVID-19 had severe acute respiratory syndrome coronavirus 2 infection diagnosed by nasopharyngeal/oropharyngeal swabs and were treated according to local therapeutic procedures.

Main outcomes and measures: The primary study outcome was the incidence of full-thickness tracheal lesions or tracheoesophageal fistulas in patients with prolonged invasive mechanical ventilation.

Results: The mean (SD) age was 68.8 (9.0) years in the COVID-19 group and 68.5 (14.1) years in the control group (effect size, 0.3; 95% CI, -5.0 to 5.6). Eight (27%) and 15 (33%) women were enrolled in the COVID-19 group and the control group, respectively. Fourteen patients (47%) in the COVID-19 group had full-thickness tracheal lesions (n = 10, 33%) or tracheoesophageal fistulas (n = 4, 13%), while 1 patient (2.2%) in the control group had a full-thickness tracheal lesion (odds ratio, 38.4; 95% CI, 4.7 to 316.9). Clinical and radiological presentations of tracheal lesions were pneumomediastinum (n = 10, 71%), pneumothorax (n = 6, 43%), and/or subcutaneous emphysema (n = 13, 93%).

Conclusions and relevance: In this cohort study, almost half of patients with COVID-19 developed full-thickness tracheal lesions and/or tracheoesophageal fistulas after prolonged invasive mechanical ventilation. Attempts to prevent these lesions should be made and quickly recognized when they occur to avoid potentially life-threatening complications in ventilated patients with COVID-19.

Figure 1.. Early Tracheal Complications

A, Bronchoscopic image showing a full-thickness tracheal lesion of the pars membranacea. B, Axial chest computed tomography (CT) scan showing a full-thickness tracheal lesion of the pars membranacea. C, Bronchoscopic image showing a tracheoesophageal fistula. D, Axial chest CT scan showing a tracheoesophageal fistula. The white arrowhead indicates full-thickness tracheal lesion; pink arrowhead, tracheoesophageal fistula; blue arrowhead, nasogastric tube. CT indicates cuff tube; E, esophagus; T, trachea.

Figure 2.. Late Tracheal Complications

A, Coronal chest computed tomography (CT) scan showing a tracheal stenosis. B, Axial chest CT scan showing a tracheomalacia. See the loss of the tracheal rings and the large size of the tracheal lumen, which is kept patent by the tracheostomy tube. The pink arrowhead indicates tracheal stenosis.